Co mmu n i t y Heal t h Need s Assessmen t Car r ington Ar ea · 2016 Co mmu n i t y Heal t h Need s Assessmen t Car r ington Ar ea Nort h Dakot a K e n Hall, J D Shana L . W. Hall,

2016Community Health Needs Assessment

Carrington Area North DakotaKen Hall, JD

Shana L.W. Hall, MS, BSN, RN

Table of Contents Executive Summary .......................................................................................................................... 3

Overview and Community Resources ............................................................................................... 6

Assessment Process .......................................................................................................................... 14

Demographic Information ................................................................................................................ 18

Health Conditions, Behaviors, and Outcomes .................................................................................. 19

Survey Results .................................................................................................................................. 26

Findings from Focus Group and Key Informant Interviews .............................................................. 48

Priority of Health Needs ................................................................................................................... 51

Appendix A – Survey Instruments .................................................................................................... 52

Appendix B – County Health Rankings Model .................................................................................. 66

Appendix C – Prioritization of Community’s Health Needs .............................................................. 67

Appendix D – Response to Previous Assessment ............................................................................ 69

This project was supported, in part, by the Federal Office of Rural Health, Health Resources and Services Administration (HRSA) of the U.S. Department of Health and Human Services (HHS), Medicare Rural Flexibility Hospital Grant program. This information or content and conclusions are those of the author and should not be construed as the official position or policy of, nor should any endorsements be inferred by, HRSA, HHS or the U.S. Government.

_____________________________________________________________________________________________ Community Health Needs Assessment 3

Executive Summary To help inform future decisions and strategic planning, CHI St. Alexius Health, Carrington and Foster County Public Health conducted a community health needs assessment in Foster County as well as surrounding counties. The assessment sought input from area community members and health care professionals as well as analysis of community health-‐related data. To gather feedback from the community, residents of the Carrington area and surrounding region were provided the opportunity to participate in a survey. Approximately 238 residents took the survey. Additional information was collected through a focus group and key informant interviews with community leaders. The input from all of these residents represented the broad interests of the area communities. Together with secondary data gathered from a wide range of sources, the information gathered presents a snapshot of health needs and concerns in the community. The demographics of the area reflect the overall makeup of North Dakota in many respects, but residents tend to be older than the state as a whole and are less likely to have completed a four-‐year degree, which can have workforce implications. Data compiled by County Health Rankings show that as compared to North Dakota generally, Foster County is doing considerably better on measures of health outcomes and health factors. The county ranked 3rd of all North Dakota Counties on health outcomes and 8th on health factors. There also is room for improvement on certain individual factors that influence health. Factors on which Foster County was performing poorly relative to the rest of the state included:

• Rate of diabetics • Physical inactivity • Alcohol-‐impaired driving deaths • Mental health providers • Preventable hospital stays • Unemployment • Children in single-‐parent households

Of 74 potential community and health needs listed in the survey, residents who took the survey chose nine needs as the most important:

• Ability to recruit and retain primary care providers • Cancer • Obesity/overweight • Youth alcohol use and abuse (including binge drinking)


• Cost of health insurance • Availability of primary care providers • Availability of specialists • Attracting and retaining young families • Affordable housing

The survey also revealed that the biggest barriers to receiving health care as perceived by community members were not enough specialists, not enough medical providers, and the inability to get appointments or limited appointment hours. When asked what the good aspects of the area were, respondents indicated that the top community assets were:

• Safe place to live, little/no crime • Family-‐friendly; good place to raise kids • Friendly, helpful, and supportive people • Active faith community • Quality health care • Residents are involved in community

Input from community leaders provided via key informant interviews and a focus group echoed many of the concerns raised by survey respondents. Thematic concerns emerging from these sessions were:

• Adequate childcare services • Availability of substance abuse/treatment services • Ability to recruit and retain primary care providers • Prevalence of obesity, overweight • Cost of health insurance • Adult alcohol use and abuse • Youth alcohol use and abuse • Political unrest

Following careful consideration of the results and findings of this assessment, Community Group members determined that, in their estimation, the significant health needs or issues in the community are:

• Obesity/overweight • Adequate childcare services • Youth alcohol use and abuse • Adult cyber bullying • Adult alcohol use and abuse


• Lack of mental health providers


Overview and Community Resources The purpose of conducting a community health assessment is to describe the health of local people, identify areas for health improvement, identify use of local health care services, determine factors that contribute to health issues, identify and prioritize community needs, and help health care and community leaders identify potential action to address the community’s health needs. A health needs assessment benefits the community by: 1) collecting timely input from the local community; 2) providing an analysis of secondary data related to health-‐related behaviors, conditions, risks, and outcomes; 3) compiling and organizing information to guide decision making, education, and marketing efforts, and to facilitate the development of a strategic plan; and 4) engaging community members about the future of health care. Completion of a health assessment also is a requirement for public health departments seeking accreditation.

With assistance from Prairie Health Partners and the Center for Rural Health at the University of North Dakota School of Medicine and Health Sciences, CHI St. Alexius Health, Carrington and Foster County Public Health completed a community health assessment that focused on Foster County, but also considered population health information and survey responses from surrounding counties. Many community members and stakeholders worked together on the assessment.

CHI St. Alexius Health, Carrington Medical Center is located in a frontier area and is licensed as a critical access hospital with two provider-‐based clinics. One clinic is attached to the Carrington hospital and the other is located 16 miles to the north in New Rockford. Carrington is located in east central North Dakota, just two hours from four major cities in North Dakota: Fargo, Minot, Grand Forks, and Bismarck. Counties served by CHI St. Alexius Health, Carrington include Foster County and Eddy County in their entirety, plus portions of Stutsman and Wells. Other hospitals are located in both Stutsman and Wells counties. This service area is defined based on the location of the medical facilities, the geographic distance to other hospitals, and the history of usage by consumers. Located in the hospital’s service area are the communities of Bowdon,


Carrington, Cathay, Fessenden, Glenfield, Grace City, McHenry, New Rockford, Pingree, Sykeston, and Woodworth.

Figure 1: Eddy, Foster, Stutsman and Wells counties, North Dakota

CHI St. Alexius Health - Carrington Medical Center CHI St. Alexius Health, Carrington began delivering its health care mission in 1916 as the Carrington Hospital. In 1941, the hospital was leased to the Presentation Sisters of the Fargo Diocese. The Presentation Sisters joined the Catholic Health Corporation of Omaha in 1980 and later became part of Catholic Health Initiatives. In 2014 and 2015, CHI St. Alexius Health, Carrington was recognized as a “Health Strong Hospital” by being one of the top 100 Critical Access Hospitals in the United States. Additionally, CHI St. Alexius Health, Carrington was named one of the top 20 Critical Access Hospitals in 2014 by the National Rural Health Association.

CHI St. Alexius Health officially announced the formation of its regional health care system on April 19, 2016. The system is the largest health care delivery system in central and western North Dakota and is comprised of a tertiary hospital in Bismarck, and critical access hospitals (CAHs) in Carrington, Dickinson, Devils Lake, Garrison, Turtle Lake, Washburn and Williston and numerous clinics and outpatient services. CHI St. Alexius Health manages four CAHs in North


Dakota: Ashley, Elgin, Linton, and Wishek, as well as Mobridge Regional Medical Center in Mobridge, S.D.

Catholic Health Initiatives, a nonprofit, faith-‐based health system formed in 1996 through the consolidation of four Catholic health systems, expresses its mission each day by creating and nurturing healthy communities in the hundreds of sites across the nation where it provides care. The nation’s second-‐largest nonprofit health system, Englewood, Colorado-‐based CHI operates in 19 states and comprises 102 hospitals, including four academic health centers and major teaching hospitals as well as 30 critical-‐access facilities; community health-‐services organizations; accredited nursing colleges; home-‐health agencies; living communities; and other facilities and services that span the inpatient and outpatient continuum of care. In fiscal year 2015, CHI provided almost $970 million in financial assistance and community benefit – an 8% increase over the previous year -‐-‐ for programs and services for the poor, free clinics, education and research. Financial assistance and community benefit totaled more than $1.6 billion with the inclusion of the unpaid costs of Medicare. The health system, which generated operating revenues of $15.2 billion in fiscal year 2015, has total assets of approximately $23 billion.

Mission

Catholic Health Initiatives states its mission as follows: “The Mission of Catholic Health Initiatives is to nurture the healing ministry of the Church, supported by education and research. Fidelity to the Gospel urges us to emphasize human dignity and social justice as we create healthier communities.” To fulfill this mission, Catholic Health Initiatives, as a values-‐driven organization, will: • Assure the integrity of the healing ministry in both current and developing organizations

and activities; • Develop creative responses to emerging health care challenges; • Promote mission integration and leadership formation throughout the entire organization; • Create a national Catholic voice that advocates for systemic change and influences health

policy with specific concern for persons who are poor, alienated and underserved; and


• Steward resources by general oversight of the entire organization. Vision

Catholic Health Initiatives states that its vision is to live up to its name as one CHI:

• Catholic: Living our Mission and Core Values. • Health: Improving the health of the people and communities we serve. • Initiatives: Pioneering models and systems of care to enhance care delivery.

Specific services provided locally by CHI St. Alexius Health, Carrington are:

Medical & Urgent Care Services

• DOT Exams • Family Practice • Elder Care • Health Maintenance Exams • Nursing Home Rounds

• Pediatrics and Well Child Exams • Phone Nurse • Prenatal Obstetrics • Preoperative Exams • Women's Health

Inpatient Services

• Inpatient Care • Respite Care

• Swing Bed Services

Surgical Services

• Endoscopes – Colonoscopies, Gastroscopies

• General Surgery

• Ophthalmology – Cataract • Orthopedics • Vein Ablation/Varicose Vein Procedure

Outpatient Services

• Cardiac Services -‐ Cardiac Rehabilitation, Stress testing, Cardiac Rehab Support Group

• Diabetic Services -‐ Individual and group diabetes education, Diabetic Support Group

• Hospice and Home Health – Available by referral

• IV Therapy – Antibiotic, PICC line cares, port cares

• Medical Nutrition Therapy -‐ Dietitian services • Mental Health Services -‐ Available by referral • Occupational Therapy Services • Social Ministries – Healthy Communities, Faith in

Action • Physical Therapy Services • Pulmonary Rehabilitation • Sleep Disorder / Apnea Testing • Speech and Hearing Services


• Radiology -‐ Back and Joint Injections, CT and DEXA scans, echocardiograms, EKG, fluoroscopy, general x-‐ray, digital mammography, MRI, cardiac stress testing with nuclear medicine, ultrasound

• Telemedicine—Diabetes, pharmacy, sleep study

• Volunteer Auxiliary Services -‐ Courtesy Cart, Gift Shop

• Weight Management Support Group

Foster County Public Health Foster County Public Health provides public health services that encompass all residents aged birth to death. Services include environmental health, nursing services, WIC (women, infants, and children) program, health screenings and education services. Each of these programs provides a wide variety of services in order to accomplish the mission of public health, which is to assure that Foster County is a healthy place to live and each person has an equal opportunity for optimal health. To accomplish this mission, FCPH is committed to the prevention of disease and injury, promotion of healthy lifestyles, protection and enhancement of the environment, and provision of quality health care services for the people of Foster County.

Specific services provided locally by Foster County Public Health are:

• Alcohol Prevention efforts for youth and adults

• Angel Tree project at Christmas • Blood pressure checks • Car seat program • Child health (weight checks, ear

checks, etc.) • Blood sugar and Hemoglobin testing • Emergency response and

preparedness program • Family Planning Services for both

females and males

• Flu shots for children six months and older • Health Tracks (child health screening) • Home visits – chronic disease maintenance,

medication set-‐ups • Hepatitis C/HIV testing • Immunizations – all ages • Injections – Depo Estradiol, Depo Provera,

Depo Testosterone, Vit B12 • Lice checks in the school, daycare or office

setting • Office visits and consults • Preschool Screening assistance


• Radon testing kits • School health (Safe Dates, puberty

talks, school immunizations) • Sewer Permit applications for

county residents • Tobacco Prevention and Control • Tuberculosis testing and

management • Water Testing Kits

• Wellness To Businesses (flu shots, Tetanus and other immunizations, education, and health screenings)

• West Nile program—surveillance and education (mosquitoes)

• WIC (Women, Infants & Children) Program • Youth education programs (bike safety, etc.)

Community Resources Along with health care, the economy is based on agri-‐business, service industries, and retail trade. Foster County is 644 square miles of land located in the center of North Dakota. It is one of the smallest of the state's 53 counties, 18 miles by 36 miles in dimension. It is bordered by Eddy, Griggs, Stutsman and Wells counties. Foster is divided into 18 townships with the seat of county government located in Carrington.

Other health care facilities and services in Foster, Eddy and Wells Counties include: six dentists, four chiropractors, two massage therapists, and four optometrists. Each county has a long-‐term health care center with various additional levels of care and services. Foster, Eddy and Wells County Social Services also offer bathing, housekeeping, and meal preparation services through Quality Service Providers.

Carrington has a number of community assets and resources that can be mobilized to address population health improvement. In terms of physical assets and features, the community includes a bike path, fitness center, facility available for winter walking, swimming pool, city park, tennis courts, golf course, movie theatre, local winery and garden, and birding drives. Foster County offers several cultural attractions such as the Foster County Museum, which pays tribute to the early history of the city and region.


Carrington offers public transportation through South Central Transit and through Faith In Action – an entity of CHI St. Alexius Health, Carrington. The community also has a grocery store and two pharmacies with delivery services. The Carrington school system offers a comprehensive program for students K-‐12. The school system offers limited preschool options, although privately funded preschool is available in the community. Some licensed as well as unlicensed daycares are available in the area.

Hospice Agencies: • CHI Health at Home Home Health Agencies: • CHI Health at Home • Jamestown Regional Medical Center Home Health & Hospice Nursing Homes: • Golden Acres Nursing Home/Assisted Living -‐ Carrington • St. Aloisius Medical Center – Harvey • Lutheran Home of the Good Shepherd – New Rockford • Evergreen – Sherry Anderson – New Rockford Senior Citizens Center: • Carrington Senior Citizens Center (Meals on Wheels, Senior Center meals, activities) • Eddy County Senior Services • James River Senior Services • Wells-‐Sheridan County Senior Services • McHenry Senior Services • Glenfield Senior Services Public Health Services: • Foster County Public Health • Eddy County Public Health • Wells County Public Health • Stutsman County Public Health Home and Community Based Services: • Foster & Eddy County Services for the disabled and elderly • Wells County Services for the disabled and elderly • Stutsman County Services for the disabled and elderly


County Social Service Agencies/Medicaid Providers • Foster County • Eddy County • Wells County • Stutsman County Other Community Resources: • Options – a resource center for Independent Living • IPAT -‐ The Interagency Program for Assistive Technology (IPAT) • ND Department of Human Services and Regional Human Services Center • ND Aging and Disability Resource Link • Life Alert Food Assistance: • Carrington’s Daily Bread Food Pantry • Grocery delivery in Carrington from Leevers Help with Rides to Medical Appointments: • Faith In Action -‐ rides to Medical appointments in or out of town • South Central Transit -‐ transportation within Carrington city limits and some availability

within Foster County Help for the Homeless: • Bismarck – Homeless Coalition • Fargo – Salvation Army • Jamestown – Salvation Army


Assessment Process Prairie Health Partners, a Grand Forks-‐based consulting firm, working closely with the Center for Rural Health, provided substantial support to CHI St. Alexius Health, Carrington and Foster County Public Health in conducting this needs assessment. Professionals from Prairie Health Partners have conducted dozens of comprehensive community health needs assessments and community development activities in a wide variety of communities, including many rural communities. The Center for Rural Health is one of the nation’s most experienced organizations committed to providing leadership in rural health. Its mission is to connect resources and knowledge to strengthen the health of people in rural communities. As the federally designated State Office of Rural Health (SORH) for the state and the home to the North Dakota Medicare Rural Hospital Flexibility (Flex) program, the Center connects the School of Medicine and Health Sciences and the university to rural communities and their health institutions to facilitate developing and maintaining rural health delivery systems. In this capacity the Center works both at a national level and at state and community levels.

The assessment process was collaborative. Professionals from both CHI St. Alexius Health, Carrington and Foster County Public Health were heavily involved in planning and implementing the process. They met regularly by telephone conference and via email with representatives from Prairie Health Partners. The process closely followed a model used during the last community health needs assessment cycle. CHI St. Alexius Health, Carrington did not receive any written comments from the public on the previous community health needs assessment or its most recent implementation strategy. In response to the previous assessment findings, CHI St. Alexius Health, Carrington implemented a number of programs and initiatives, as detailed in Appendix D. Periodic updates to the implementation strategy included in Appendix D have been highlighted in blue.

As part of the assessment’s overall collaborative process, Prairie Health Partners spearheaded efforts to collect data for the assessment in a variety of ways:

• A survey solicited feedback from area residents;

• Community leaders representing the broad interests of the community took part in one-‐on-‐one key informant interviews;

• The Community Group, comprised of community leaders and area residents, was convened to discuss area health needs and inform the assessment process; and

• A wide range of secondary sources of data was examined, providing information on a multitude of measures including demographics; health conditions, indicators, and outcomes; rates of preventive measures; rates of disease; and at-‐risk behaviors.


Detailed below are the methods undertaken to gather data for this assessment by convening a Community Group, conducting key informant interviews, soliciting feedback about health needs via a survey, and researching secondary data.

Community Group A Community Group consisting of 18 community members was convened and first met on March 14, 2016. During this first Community Group meeting, group members were introduced to the needs assessment process, reviewed basic demographic information about Foster County, as well as Eddy, Stutsman and Wells counties, and served as a focus group. Focus group topics included community assets and challenges, the general health needs of the community, community concerns, and suggestions for improving the community’s health.

The Community Group met again on May 9, 2016 with 16 community members in attendance. At this second meeting the Community Group was presented with survey results, findings from key informant interviews and the focus group, and a wide range of secondary data relating to the general health of the population in Foster, Eddy, Stutsman and Wells counties. The group was then tasked with identifying and prioritizing the community’s health needs.

Members of the Community Group represented the broad interests of the community served by CHI SAHC and FCPH. They included representatives of the health community, business community, economic development, political bodies, law enforcement, emergency services, education, faith community, and public health. Not all members of the group were present at both meetings.

Interviews One-‐on-‐one interviews with six key informants were conducted in person in Carrington on March 14, 2016. Representatives from Prairie Health Partners conducted the interviews. Interviews were held with selected members of the Community Group as well as other key informants who could provide insights into the community’s health needs. Included among the informants were a public health professional with special knowledge in public health acquired through several years of direct experience in the community, including working with medically underserved, low income, and minority populations, as well as with populations with chronic diseases.

Topics covered during the interviews included the general health of the community, community concerns, delivery of health care by local providers, awareness of health services offered locally, barriers to receiving health services, and suggestions for improving collaboration within the community.

Survey A survey was distributed to gather feedback from the community. The survey was not intended to be a scientific or statistically valid sampling of the population. Rather, it was designed to be an additional tool for collecting qualitative data from the community at large – specifically, information related to community-‐perceived health needs and assets.


The survey was distributed to various residents of Foster County and the other counties served by CHI St. Alexius Health, Carrington. The survey tool was designed to:

• Learn of the good things in the community and the community’s concerns; • Understand perceptions and attitudes about the health of the community, and hear

suggestions for improvement; and • Learn more about how residents use local health services.

Specifically, the survey covered the following topics:

• Residents’ perceptions about community assets • Broad areas of community and health concerns • Intimate partner violence • Awareness of local health services • Barriers to using local health care • Hospital foundation awareness • Basic demographic information • Suggestions to improve the delivery of local health care

Approximately 500 community member surveys were available for distribution. To promote awareness of the assessment process, press releases led to articles in two newspapers in Foster and Eddy counties including in the communities of Bowdon, Carrington, Fessenden, Glenfield, Grace City, Kensal, New Rockford, Pingree, and Woodworth. Additionally, information was published on CHI SAHC’s website and FCPH’s Facebook page.

The surveys were distributed by Community Group members and at CHI SAHC, FCPH, and local churches. To help ensure anonymity, each survey included a postage-‐paid return envelope to the Center for Rural Health. In addition, to help make the survey as widely available as possible, residents also could request a survey by calling CHI SAHC or FCPH. Area residents also were given the option of completing an online version of the survey, which was publicized in two community newspapers, emailed to at least 25 community groups, and on the websites of both CHI SAHC and FCPH.

The survey period ran from February 18 to March 31, 2016, and 74 paper surveys were returned, while 164 online electronic surveys were taken. In total, counting both paper and online surveys, 238 community member surveys were submitted. The response rate is on par for this type of unsolicited survey methodology and indicates an engaged community.

Secondary Data Secondary data was collected and analyzed to provide descriptions of: (1) population demographics, (2) general health issues (including any population groups with particular health issues), and (3) contributing causes of community health issues. Data were collected from a variety of sources including the U.S. Census Bureau; the Robert Wood Johnson Foundation’s County Health Rankings (which pulls data from more than 20 primary data sources); the National Survey of Children’s Health Data Resource Center; the Centers for Disease Control and


Prevention; the North Dakota Behavioral Risk Factor Surveillance System; and the National Center for Health Statistics.


Demographic Information Table 1 summarizes general demographic and geographic data about Eddy, Foster, Stutsman and Wells counties.

TABLE 1: EDDY, FOSTER, STUTSMAN & WELLS COUNTIES: INFORMATION AND DEMOGRAPHICS

(From 2010 Census/2014 American Community Survey; more recent estimates used where available)

Eddy County

Foster County

Stutsman County

Wells County

North Dakota

Population (2014 est.) 2,377 3,362 21,129 4,192 739,482 Population change (2010-‐2014) -‐0.3% 0.6% 0.1% -‐0.4% 9.9% People per square mile (2010) 3.8 5.3 9.5 3.3 9.7 Persons 65 years or older (2014 est.) 23.8% 22.0% 17.6% 27.1% 14.2% Persons under 18 years (2014 est.) 22.2% 21.4% 20.4% 19.2% 22.8% Median age (2014 est.) 48.8 46.4 41.1 51.2 35.9 White persons (2014 est.) 93.0% 97.4% 95.1% 97.7% 89.1% Non-‐English speaking (2014 est.) 2.2% 4.4% 4.9% 2.6% 5.4% High school graduates (2014 est.) 86.6% 88.1% 87.3% 84.1% 91.3% Bachelor’s degree or higher (2014 est.) 19.9% 20.0% 22.3% 19.7% 27.3% Live below poverty line 10.7% 8.0% 11.6% 10.9% 11.5% Children under 18 in poverty (2013) 20.9% 10.1% 18.7% 9.0% 14.1%

While the population of North Dakota has grown in recent years, the populations of the four counties studied were stable with modest changes between 2010 and 2014. The data show that the area is rural and that its residents are older than the state as a whole and are less likely to have completed a four-‐year degree, which can have workforce implications. Eddy and Stutsman counties had higher levels of children in poverty than North Dakota overall, while Foster and Wells counties experienced lower rates of children in poverty.


Health Conditions, Behaviors, and Outcomes

As noted above, several sources of secondary data were reviewed to inform this assessment. The data are presented below in two categories: County Health Rankings and children’s health.

County Health Rankings

The Robert Wood Johnson Foundation, in collaboration with the University of Wisconsin Population Health Institute, has developed County Health Rankings to illustrate community health needs and provide guidance for actions toward improved health. In this report, Eddy, Foster, Stutsman and Wells counties are compared to North Dakota rates and national benchmarks on various topics ranging from individual health behaviors to the quality of health care.

The data used in the 2016 County Health Rankings are pulled from more than 20 data sources and then are compiled to create county rankings. Counties in each of the 50 states are ranked according to summaries of a variety of health measures. Those having high ranks, such as 1 or 2, are considered to be the “healthiest.” Counties are ranked on both health outcomes and health factors. As shown in Table 2 below, for example, Foster County ranks 3rd out of 49 ranked counties in North Dakota on health outcomes and 8th on health factors.

Below is a breakdown of the variables that influence a county’s rank. A model of the 2016 County Health Rankings – a flow chart of how a county’s rank is determined – may be found in Appendix B. For further information, visit the County Health Rankings website at www.countyhealthrankings.org.


Table 2 summarizes the pertinent information gathered by County Health Rankings as it relates to the counties in the assessment area. It is important to note that these statistics describe the population of a county regardless of where county residents choose to receive their medical care. In other words, all of the following statistics are based on the health behaviors and conditions of the county’s residents, not necessarily the patients and clients of CHI St. Alexius Health, Carrington and Foster County Public Health or of particular medical facilities.

For most of the measures included in the rankings, the County Health Rankings’ authors have calculated the “Top U.S. Performers” for 2016. The Top Performer number marks the point at which only 10% of counties in the nation do better, i.e., the 90th percentile or 10th percentile, depending on whether the measure is framed positively (such as high school graduation) or negatively (such as adult smoking).

As shown in the key below, the measures listed in Table 2 marked with a red checkmark (ü) are those where a county is not measuring up to the state rate/percentage; a blue checkmark (ü) indicates that the county may be faring better than the North Dakota average, but is not meeting the U.S. Top 10% rate on that measure. Measures marked with a smiling icon (J) indicate that the county is in the U.S. Top 10% of counties on that measure.

ü = County is worse than the state average

ü = County is not meeting the Top 10% nationally

J = County in Top 10% nationally


TABLE 2: SELECTED MEASURES FROM 2016 COUNTY HEALTH RANKINGS

Eddy County

Foster County

Stutsman County

Wells County

U.S. Top 10%

North Dakota

Ranking: Outcomes 41st 3rd 36th 28th (of 49) Premature death -‐ 5,200 J 7,400 üü 8,100 üü 5,200 6,600 Poor or fair health 14% ü 11% J 11% J 12% J 12% 14% Poor physical health days (in past 30 days) 3.0 üü 2.5 J 2.4 J 2.6 J 2.9 2.9

Poor mental health days (in past 30 days) 2.9 ü 2.5 J 2.5 J 2.6 J 2.8 2.9

Low birth weight -‐ 4% J 9% üü -‐ 6% 6% % Diabetic 12% üü 10% üü 8% J 10% üü 9% 8%

Ranking: Factors 39th 8th 27th 37th (of 49) Health Behaviors

Adult smoking 19% ü 16% ü 17% ü 16% ü 14% 20% Adult obesity 32% üü 29% ü 30% ü 32% üü 25% 30% Food environment index 8.1 üü 8.9 J 8.4 J 8.1 üü 8.3 8.4 Physical inactivity 29% üü 34% üü 29% üü 33% üü 20% 25% Access to exercise opportunities 62% üü 68% ü 79% ü 1% üü 91% 66%

Excessive drinking 19% ü 21% ü 22% ü 19% ü 12% 25% Alcohol-‐impaired driving deaths 75% üü 67% üü 43% ü 40% ü 14% 47%

Sexually transmitted infections -‐ -‐ 219.7 ü 93.7 J 134.1 419.1

Teen birth rate 23 ü 22 ü 23 ü 27 ü 19 28 Clinical Care

Uninsured 15% üü 12% ü 12% ü 13%üü 11% 12% Primary care physicians -‐ 1120:1ü 1320:1üü 4210:1üü 1040:1 1260:1 Dentists 790:1 J 1680:1ü 1510:1 ü 1400:1 ü 1340:1 1690:1 Mental health providers -‐ 3360:1üü 350:1 J -‐ 370:1 610:1 Preventable hospital stays 71 üü 64 üü 45 ü 87 üü 38 51 Diabetic monitoring 80% üü 87% ü 86% ü 72% üü 90% 86% Mammography screening 71% J 79% J 73% J 71% J 71% 68%

Social and Economic Factors Unemployment 5.9% üü 3.2% ü 2.9% ü 4.8% üü 3.5% 2.8% Children in poverty 14% ü 10% J 14% ü 14% ü 13% 14% Income inequality 4.4 ü 4.3 ü 4.1 ü 4.3 ü 3.7 4.4 Children in single-‐parent households 41% üü 36% üü 42% üü 16% J 21% 27%

Violent crime 55 J 11 J 186 ü 140 ü 59 240 Injury deaths 126 üü 60 ü 66 üü 95 üü 51 63

Physical Environment Air pollution – particulate matter 9.8 ü 9.9 ü 10.0 ü 9.6 ü 9.5 10.0

Drinking water violations No No Yes Yes No Severe housing problems 8% J 11% ü 7% J 8% J 9% 11%


Foster County Summary The data from County Health Rankings show that Foster County is in top 10% of counties nationally on a number of studied measures:

• Premature death • Self-‐reported poor or fair health • Self-‐reported poor physical

health days • Self-‐reported poor mental

health days

• Low birth weight • Food environment index • Mammography screening • Children in poverty • Violent crime

The data revealed, however, that Foster County is faring worse than North Dakota averages on the following measures:

• Rate of diabetics • Physical inactivity • Alcohol-‐impaired driving deaths • Mental health providers

• Preventable hospital stays • Unemployment • Children in single-‐parent

households

Other measures where Foster County tended to do better than the state overall, but was not performing in the top 10% of counties nationally were:

• Rate of diabetics • Adult smoking • Adult obesity • Physical inactivity • Access to exercise opportunities • Excessive drinking • Alcohol-‐impaired driving deaths • Teen birth rate • Uninsured residents • Primary care physicians

• Dentists • Mental health providers • Preventable hospital stays • Diabetic monitoring • Income inequality • Children in single-‐parent

households • Injury deaths • Air pollution – particulate matter • Severe housing problems

Eddy County Summary The data from County Health Rankings show that Eddy County is in top 10% of counties nationally on a few studied measures:

• Dentists • Mammography screening

• Severe housing problems • Violent crime


The data revealed, however, that Eddy County is faring worse than North Dakota averages on the following measures:

• Self-‐reported poor physical health days

• Rate of diabetics • Adult obesity • Food environment index • Physical inactivity • Access to exercise opportunities • Alcohol-‐impaired driving deaths

• Uninsured residents • Preventable hospital stays • Diabetic monitoring • Unemployment • Children in single-‐parent

households • Injury deaths

Other measures where Eddy County tended to do better than the state overall, but was not performing in the top 10% of counties nationally were:

• Self-‐reported poor or fair health • Self-‐reported poor mental

health days • Adult smoking • Excessive drinking

• Teen birth rate • Children in poverty • Income inequality • Air pollution – particulate matter


Children’s Health The National Survey of Children’s Health touches on multiple intersecting aspects of children’s lives. Data are not available at the county level; listed below is information about children’s health in North Dakota. The full survey includes physical and mental health status, access to quality health care, and information on the child’s family, neighborhood, and social context. Data are from 2011-‐12. More information about the survey may be found at: www.childhealthdata.org/learn/NSCH. Key measures of the statewide data are summarized below. The rates highlighted in red signify that the state is faring worse on that measure than the national average.

TABLE 3: SELECTED MEASURES REGARDING CHILDREN’S HEALTH (For children aged 0-‐17 unless noted otherwise)

Health Status North Dakota

National

Children born premature (3 or more weeks early) 10.8% 11.6% Children 10-‐17 overweight or obese 35.8% 31.3% Children 0-‐5 who were ever breastfed 79.4% 79.2% Children 6-‐17 who missed 11 or more days of school 4.6% 6.2%

Health Care Children currently insured 93.5% 94.5% Children who had preventive medical visit in past year 78.6% 84.4% Children who had preventive dental visit in past year 74.6% 77.2% Young children (10 mos.-‐5 yrs.) receiving standardized screening for developmental or behavioral problems

20.7% 30.8%

Children aged 2-‐17 with problems requiring counseling who received needed mental health care

86.3% 61.0%

Family Life Children whose families eat meals together 4 or more times per week 83.0% 78.4% Children who live in households where someone smokes 29.8% 24.1%

Neighborhood Children who live in neighborhood with a park, sidewalks, a library, and a community center

58.9% 54.1%

Children living in neighborhoods with poorly kept or rundown housing 12.7% 16.2% Children living in neighborhood that’s usually or always safe 94.0% 86.6%

The data on children’s health and conditions reveal that while North Dakota is doing better than the national averages on some measures, it is not measuring up to the national averages with respect to:

• Obese or overweight children • Children with health insurance • Preventive primary care and dentist visits • Developmental/behavioral screening • Children in smoking households


Table 4 includes selected county-‐level measures regarding children’s health in North Dakota. The data come from North Dakota KIDS COUNT, a national and state-‐by-‐state effort to track the status of children, sponsored by the Annie E. Casey Foundation. KIDS COUNT data focus on main components of children’s well being; more information about KIDS COUNT is available at www.ndkidscount.org. The measures highlighted in red in the table are those in which that county is doing worse than the state average. The year of the most recent data is noted.

The data show that the area suffers from higher rates of uninsured children and a lack of licensed childcare services. Notably, the number of children that can be served by licensed childcare providers in Foster County is less than half the state rate.

TABLE 4: SELECTED COUNTY-‐LEVEL MEASURES REGARDING CHILDREN’S HEALTH

Eddy County

Foster County

Stutsman County

Wells County

North Dakota

Uninsured children (% of population age 0-‐18), 2013 11.5% 10.4% 8.7% 10.4% 8.7%

Uninsured children below 200% of poverty (% of population), 2013 54.0% 57.7% 49.1% 56.5% 47.8%

Medicaid recipient (% of population age 0-‐20), 2015 29.5% 26.7% 26.8% 25.7% 27.9%

Children enrolled in Healthy Steps (% of population age 0-‐18), 2013 4.8% 2.4% 3.0% 2.4% 2.5%

Supplemental Nutrition Assistance Program (SNAP) recipients (% of population age 0-‐18), 2015

15.7% 14.5% 18.2% 15.6% 20.7%

Licensed childcare capacity (% of population age 0-‐13), 2016 27.9% 22.1% 36.5% 32.8% 44.5%

High school dropouts (% of grade 9-‐12 enrollment), 2014 0% 0% 3.1% 1.3% 2.8%


Survey Results As noted previously, 238 community members took the survey in communities throughout the assessment area. Survey results are reported below in six categories:

• Demographics • Health insurance status • Community assets • Community concerns • Delivery of health care • CHI Carrington Health Foundation

Demographics To better understand the perspectives being offered by survey respondents, survey-‐takers were asked a few demographic questions. Throughout this report, numbers (N) instead of percentages (%) are reported because percentages can be misleading with smaller numbers. Survey respondents were not required to answer all survey questions; they were free to skip any questions they wished. With respect to demographics of those who chose to take the survey:

• The survey attracted a fairly even distribution of ages. The most represented groups were those aged 35 to 44 and 45 to 54, with 46 and 45 respondents, respectively.

• The large majority were female, with a ratio of female-‐to-‐male of more than three-‐to-‐one.

• Slightly more than half of respondents (N=99) had bachelor’s degrees or higher, with a plurality of respondents (N=67) having bachelor’s degrees.

• A large majority (N=129) worked full-‐time, with retirees (N=32) being the next largest group.

• A plurality (N=44) of respondents who chose to provide household income reported income in the range of $100,000 to $149,999.

Figure 2 shows these demographic characteristics. It illustrates the wide range of community members’ household income and indicates how this assessment took into account input from parties who represent the varied interests of the community served, including wide age ranges, those in diverse work situations, and lower-‐income community members. Of those who provided a household income, 12 community members reported a household income of less than $25,000, with seven of those indicating a household income of less than $15,000. Of survey-‐takers who chose to identify their race or ethnicity, 190 were white, one was Hispanic/Latino and three were American Indian.


Figure 2: Demographics of Survey Respondents

2

35

46

45

35

23 15

18 to 24 years

25 to 34 years

35 to 44 years

45 to 54 years

55 to 64 years

65 to 74 years

75 years and older

Age

153

46

Gender

Female

Male

0 26

45

26

67

32

Less than high school

High school diploma or GED

Some college/technical degree

Associate's degree

Bachelor's degree

Graduate or professional degree

Highest Educaqon

7

5

25

40

37

44

14

25

0 10 20 30 40 50

Less than $15,000

$15,000 to $24,999

$25,000 to $49,999

$50,000 to $74,999

$75,000 to $99,999

$100,000 to $149,999

$150,000 and over

Prefer not to answer Household Income

129 18 6

13 1

32

Employment Status

Full qme

Part qme

Homemaker

Mulqple job holder

Unemployed

Reqred


Survey takers were asked whether they worked for the hospital, clinic, or public health unit. As shown in Figure 3, 145 responded they did not work for these health organizations, while 38 said they did and 18 indicated they worked for another health care facility in the community.

Figure 3: Work for Hospital, Clinic or Public Health?

Health Insurance Status Community members were asked about their health insurance status. Health insurance status often is associated with whether people have access to health care. A large majority of respondents (N=168) reported having insurance that was self-‐purchased or through their employer. Thirty-‐seven reported having Medicare. Four respondents said they had no insurance, while an additional four said they were underinsured.

Figure 4: Insurance Status

38

145

18

Yes No I work for another healthcare facility in the community

1

4

4

4

8

8

37

168

0 20 40 60 80 100 120 140 160 180

Indian Health Service (IHS)

Not enough insurance

Veteran’s Health Care Benefits

No insurance

Medicaid

Other. Please specify:

Medicare

Insurance through employer or self-‐purchased


Community Assets Survey-‐takers were asked what they perceived as the best things about their community in four categories: people, services and resources, quality of life, and activities. In each category, respondents were given a list of choices and asked to pick the three best things. Respondents occasionally chose less than three or more than three choices within each category. The results indicate there is consensus (with 140 or more respondents agreeing) that community assets include:

• Safe place to live, little/no crime (N=184) • Family-‐friendly; good place to raise kids (N=177) • Friendly, helpful, and supportive people (N=156) • Active faith community (N=146) • Quality health care (N=141) • Residents are involved in community (N=141)

Figures 5 to 8 illustrate the results of these questions.

Figure 5: Best Things about the PEOPLE in Your Community

10

15

27

33

42

120

141

156

0 20 40 60 80 100 120 140 160 180 200

Other

People are tolerant, inclusive and open-‐minded

Government is accessible

Community is socially and culturally diverse or becoming more diverse

Sense that you can make a difference through civic engagement

Feeling connected to people who live here

People who live here are involved in their community

People are friendly, helpful, supporqve


Figure 6: Best Things about the SERVICES AND RESOURCES in Your Community

Figure 7: Best Things about the QUALITY OF LIFE in Your Community

Figure 8: Best Thing about the ACTIVITIES in Your Community

3

3

24

28

31

42

43

128

141

146

0 20 40 60 80 100 120 140 160 180 200

Other

Opportuniqes for advanced educaqon

Public transportaqon

Business district (restaurants, availability of goods)

Programs for youth

Community groups and organizaqons

Access to healthy food

Quality school systems

Health care

Acqve faith community

1

29

86

113

177

184

0 20 40 60 80 100 120 140 160 180 200

Other

Job opportuniqes or economic opportuniqes

Informal, simple, laidback lifestyle

Closeness to work and acqviqes

Family-‐friendly; good place to raise kids

Safe place to live, litle/no crime

10

15

83

90

92

139

0 20 40 60 80 100 120 140 160 180 200

Other

Arts and cultural acqviqes

Year-‐round access to fitness opportuniqes

Local events and fesqvals

Acqviqes for families and youth

Recreaqonal and sports acqviqes


Community Concerns At the heart of this community health assessment was a section on the survey asking survey-‐takers to review a wide array of potential community and health concerns in seven categories and asked to pick the top three concerns. The seven categories of potential concerns were:

• Community health • Availability of health services • Safety/environmental health • Delivery of health services • Physical health • Mental health and substance abuse • Senior population

The two most highly voiced concerns, chosen by at least 120 respondents, were:

• Ability to recruit and retain primary care providers (N=142) • Cancer (N=122)

The other issues that were chosen by at least 100 survey-‐takers were:

• Obesity/overweight (N=112) • Youth alcohol use and abuse (including binge drinking) (N=111) • Cost of health insurance (N=110) • Availability of primary care providers (N=106) • Availability of specialists (N=105) • Attracting and retaining young families (N=102) • Affordable housing (N=100)

Examining the survey responses from those who indicated they worked for a health care facility reveals that health care professionals generally share the same concerns as community members. Consistent with the overall survey results , health care professionals rated the top concern as the ability to recruit and retain primary care providers. They differed in that they judged the availablity of specialists as the second-‐highest concern, and also included as a top concern the inadequate number of jobs with livable wages. Top concerns of health care professionals (those chosen by at least 35 health care professionals) were:

• Ability to recruit and retain primary care providers (N=50) • Availability of specialists (N=43) • Cancer (N=41) • Obesity/overweight (N=41) • Cost of health insurance (N=40) • Attracting and retaining young families (N=37)


• Jobs with livable wages (N=35)

Figures 9 through 15 illustrate these results.

Figure 9: Community Health Concerns – All Respondents

Figure 9A: Community Health Concerns – Health Care Professionals Only

7

15

26

32

38

56

90

99

100

102

0 50 100 150

Other

Change in populaqon size

Poverty

Adequate youth acqviqes

Access to exercise and wellness acqviqes

Adequate school resources

Jobs with livable wages

Adequate childcare services

Affordable housing

Atracqng and retaining young families

2

6

8

9

13

23

25

32

35

37

0 50

Other

Change in populaqon size

Poverty

Adequate youth acqviqes

Access to exercise and wellness acqviqes

Adequate school resources

Affordable housing


Jobs with livable wages

Atracqng and retaining young families


Figure 10: Availability of Health Services Concerns – All Respondents

Figure 10A: Availability of Health Services Concerns – Health Care Professionals Only

11

17

22

24

29

52

55

76

105

106

0 50 100 150

Other

Availability of public health professionals

Availability of vision care

Availability of dental care

Availability of wellness/disease prevenqon services

Availability of mental health services

Availability of substance abuse/treatment services

Ability to get appointments

Availability of specialists

Availability of primary care providers

2

6

7

8

17

19

20

26

33

43

0 50

Other

Availability of vision care

Availability of dental care

Availability of public health professionals

Availability of wellness/disease prevenqon services

Availability of mental health services


Ability to get appointments

Availability of primary care providers

Availability of specialists


Figure 11: Safety/Environmental Health Concerns – All Respondents

Figure 11A: Safety/Environmental Health Concerns – Health Care Professionals Only

1

5

12

12

18

29

36

38

40

46

70

74

87

0 50 100 150

Low graduaqon rates

Land quality (liter, illegal dumping)

Air quality

Other

Physical violence, domesqc violence

Water quality (well water, lakes, rivers)

Crime and safety

Public transportaqon (opqons and cost)

Prejudice, discriminaqon

Traffic safety

Youth cyber bullying

Emergency services available 24/7

Adult cyber bullying

1

2

3

6

8

9

12

12

18

19

21

21

31

0 50

Low graduaqon rates

Land quality (liter, illegal dumping)

Air quality

Other

Physical violence, domesqc violence

Water quality (well water, lakes, rivers)

Traffic safety

Crime and safety

Public transportaqon (opqons and cost)

Prejudice, discriminaqon

Youth cyber bullying

Emergency services available 24/7

Adult cyber bullying


Figure 12: Delivery of Health Services Concerns – All Respondents

Figure 12A: Delivery of Health Services Concerns – Health Care Professionals Only

1

7

8

10

27

28

51

54

88

110

142

0 50 100 150

Adequacy of Indian Health or Tribal Health services

Other

Sharing of informaqon between healthcare providers

Providers using electronic health records

Paqent confidenqality

Quality of care

Extra hours for appointments, such as evenings and weekends

Cost of prescripqon drugs

Cost of health care services

Cost of health insurance

Ability to recruit and retain primary care providers

1

3

4

4

5

7

16

16

28

40

50

0 50

Adequacy of Indian Health or Tribal Health services

Other

Providers using electronic health records

Sharing of informaqon between healthcare providers

Quality of care

Paqent confidenqality

Extra hours for appointments, such as evenings and weekends

Cost of prescripqon drugs

Cost of health care services




Figure 13: Physical Health Concerns – All Respondents

2

4

5

16

18

21

27

35

40

47

47

52

112

122

0 50 100 150

Sexual health (including sexually transmited diseases/AIDS

Teen pregnancy

Other

Wellness and disease prevenqon, including vaccine-‐preventable diseases

Youth sexual health (including sexually transmited infecqons)

Lung disease (Emphysema, COPD, Asthma, etc.)

Youth hunger and poor nutriqon

Heart disease

Youth obesity

Sedentary lifestyles

Poor nutriqon, poor eaqng habits

Diabetes

Obesity/overweight

Cancer


Figure 13A: Physical Health Concerns – Health Care Professionals Only

0

2

2

5

6

6

10

11

14

16

17

23

41

41

0 50

Sexual health (including sexually transmited diseases/AIDS

Other

Teen pregnancy

Youth hunger and poor nutriqon

Wellness and disease prevenqon, including vaccine-‐preventable diseases

Youth sexual health

Lung disease (Emphysema, COPD, Asthma, etc.)

Youth obesity

Sedentary lifestyles

Poor nutriqon, poor eaqng habits

Heart disease

Diabetes

Cancer

Obesity/overweight


Figure 14: Mental Health and Substance Abuse Concerns – All Respondents

3

11

13

23

23

27

32

41

42

57

92

97

111

0 50 100 150

Other

Adult tobacco use

Adult suicide

Youth tobacco use

Youth mental health

Youth suicide

Adult mental health

Stress

Depression

Adult drug use and abuse

Youth drug use and abuse

Adult alcohol use and abuse

Youth alcohol use and abuse


Figure 14A: Mental Health and Substance Abuse Concerns – Health Care Professionals Only

Figure 15: Senior Population Concerns – All Respondents

0

4

6

8

9

9

14

15

15

16

24

29

34

0 50

Other

Adult tobacco use

Adult suicide

Youth tobacco use

Youth mental health

Youth suicide

Adult mental health

Stress

Depression

Adult drug use and abuse

Youth drug use and abuse



5

6

18

43

43

56

56

82

82

90

0 50 100 150

Elder abuse

Other

Cost of acqviqes for seniors

Availability of resources for family and friends caring for elders

Availability of acqviqes for seniors

Demenqa/Alzheimer’s disease

Long-‐term/nursing home care opqons

Ability to meet needs of older populaqon

Assisted living opqons

Availability of resources to help the elderly stay in their homes


Figure 15A: Senior Population Concerns – Health Care Professionals Only

The survey posed two questions about intimate partner violence. First, respondents were asked if they were aware of any incidents of intimate partner violence in their community. Second, they were asked whether they would report any known incidents of intimate partner violence to city or county law enforcement. A large majority of survey respondents said they were not aware of such incidencts of violence, but that they would be willing to report incidents if they were aware of them. Figure 16 shows these results.

Figure 16: Intimate Partner Violence

In an open-‐ended question, residents were asked to share other concerns and challenges, as well as suggestions to improve the delivery of local health care. Forty survey-‐takers provided

0

3

4

13

16

20

20

28

28

30

0 50

Other

Elder abuse

Cost of acqviqes for seniors

Availability of acqviqes for seniors

Long-‐term/nursing home care opqons

Demenqa/Alzheimer’s disease

Availability of resources for family and friends caring for elders

Ability to meet needs of older populaqon

Assisted living opqons

Availability of resources to help the elderly stay in their homes

33

175

Yes No

Aware of inqmate partner violence incidents in your community?

163

29

Yes No

Willing to report to law enforcement incidents of inqmate partner violence?


responses to this question. By far, the concern voiced most related to the ability to recruit and retain providers, specifically physicians. Specific comments provide some insights into residents’ perception of this issue:

• Must recruit and retain local doctors and make working conditions favorable so the doctors have a quality of life that makes them willing to stay.

• CHI needs to get some Drs. in there. We are sick of hearing that nobody wants to work in Carrington.

• Challenges bringing quality physicians to a smaller town and then when we get good ones not to overload them. Having a local physician on call for ER would be wonderful as well, but I understand they need their time off as well.

• Need to recruit good local doctors who have a connection to the community. That gives them family ties to the community and hopefully makes it more likely for them to enjoy a long career here. We can't miss any of these local recruitment opportunities when they come up.

• Not enough doctors. Those that are here are great but are over worked and run down. Burn out is very likely. Have had instances with nurses and front desk staff being rude, short with others, or crabby.

• Concern about administration not being able to secure another medical doctor, won't be long until there will only be one here!

• We need an additional physician. We are seriously over working those we have.

Other concerns noted by multiple respondents were: (1) the lack of adequate ambulance personnel and concerns that emergency services will not be available when needed, (2) the lack of community plans to attract and retain young families, as evidenced by the recent vote against funding for a new school, and (3) costs of insurance (including high deductibles and co-‐pays), health care services, and prescription drugs.


Delivery of Health Care The survey asked residents what they see as preventing them or others from receiving health care locally. The most prevalent barrier perceived by residents was not enough specialists (N=63), followed by not enough medical providers (N=58) and the inability to get appointments or limited appointment hours (N=34). Figure 17 illustrates these results.

Figure 17: Perceptions about Barriers to Care

1

2

2

4

10

13

17

20

20

25

27

34

37

38

45

58

63

0 10 20 30 40 50 60 70

Lack of disability access

Lack of services through Indian Health Service

Don’t speak language or understand culture

Limited access to telehealth technology

Can’t get transportaqon services

Poor quality of care

Distance from health facility

Don’t know about local services

Other

No insurance or limited insurance

Not affordable

Not able to see same provider over qme

Not enough evening or weekend hours

Concerns about confidenqality

Not able to get appointment/limited hours

Not enough medical providers

Not enough specialists


The survey revealed that, by a large margin, residents turned to a primary care provider (doctor, nurse practitioner, physician assistant) for trusted health information. Other common sources of trusted health information are other health care professionals (nurses, chiropractors, dentists, etc.) and web searches/Internet (WebMD, Mayo Clinic, Healthline, etc.).

Figure 18: Sources of Trusted Health Information

When asked whether they would appreciate having a trained paramedic make visits to their home following an illness, the majority of respondents replied no.

Figure 19: Appreciate Visit from Trained Paramedic Following Illness?

Services Provided by CHI St. Alexius Health, Carrington

The survey asked community members whether they were aware of (or have used) services offered locally by CHI St. Alexius Health, Carrington and by Foster County Public Health. Among services offered by the hospital, community members were most aware of:

• Family practice (N=163) • Physical therapy services (N=140)

7

45

70

104

105

169

0 20 40 60 80 100 120 140 160 180

Other

Public health professional

Word of mouth, from others (friends, neighbors, co-‐workers, etc.)

Web searches/Internet (WebMD, Mayo Clinic, Healthline, etc.)

Other health care professionals (nurses, chiropractors, denqsts, etc.)

Primary care provider (doctor, nurse pracqqoner, physician assistant)

68

114

Yes

No


• Inpatient care (N=137) • Endoscopes – colonoscopies, gastroscopies (N=133) • Radiology (N=133) • Phone nurse (N=127)

Community members were least aware of the following services:

• Respite Care (N=53) • Prenatal obstetrics (N=53) • Ophthalmology – cataract (N=54) • Orthopedics (N=62) • Pulmonary rehabilitation (N=62) • Telemedicine -‐ diabetes, pharmacy, sleep study (N=62)

These services with lower levels of awareness may present opportunities for further marketing, greater utilization, and increased revenue. Figures 20 to 23 illustrate community members’ awareness of services.

Figure 20: Awareness of Inpatient Services

Figure 21: Awareness of Surgery Services

53

106

137

0 25 50 75 100 125 150 175

Respite Care

Swing Bed Services

Inpaqent Care

54

62

73

85

133

0 25 50 75 100 125 150 175

Ophthalmology – Cataract

Orthopedics

General Surgery

Vein Ablaqon/Varicose Vein Procedure

Endoscopes – Colonoscopies, Gastroscopies


Figure 22: Awareness of Outpatient Services

Figure 23: Awareness of Clinical Services

62

62

64

71

71

71

75

79

83

89

100

106

108

110

133

140

0 25 50 75 100 125 150 175

Pulmonary Rehabilitaqon

Telemedicine -‐ Diabetes, pharmacy, sleep study

Medical Nutriqon Therapy -‐ Dieqqan services

Sleep Disorder / Apnea Tesqng

IV Therapy -‐ Anqbioqc, PICC line cares, port cares

Mental Health Services -‐ Available by referral

Weight Management Support Group

Speech and Hearing Services

Occupaqonal Therapy Services

Social Ministries -‐ Health Communiqes, Faith In Acqon

Volunteer Auxiliary Services -‐ Courtesy Cart, Gix Shop

Diabeqc Services -‐ Individual and group diabetes

Cardiac Services -‐ Cardiac Rehabilitaqon, stress

Hospice and Home Health -‐ Available by referral

Radiology -‐ Back and Joint Injecqons, CT and DEXA

Physical Therapy Services

53

64

68

79

81

84

87

112

127

163

0 25 50 75 100 125 150 175

Prenatal Obstetrics

Elder Care

DOT Exams

Women's Health

Preoperaqve Exams

Nursing Home Rounds

Pediatrics and Well Child Exams

Health Maintenance Exams

Phone Nurse

Family Pracqce


Services Provided by Foster County Public Health With respect to public health services, respondents were generally aware of some services, such as immunizations and public health care, but most survey-‐takers were unaware of several of public health’s other offerings, as shown in Figure 24:

Figure 24: Awareness of Public Health Services

19

27

32

55

61

62

63

87

88

101

105

123

162

0 25 50 75 100 125 150 175

Environmental Health

School Nursing

Health Tracks

Family Planning

Wellness Clinics

Maintenance Injecqons (Depo Provera, Depo Testosterone, Vitamin B12)

Tobacco Educaqon

Home Visits (chronic disease management, medicaqon set-‐up)

WIC

Foot Care

Car Seat Safety

Public Health Care

Immunizaqons


Hospital Foundation The survey asked residents whether (1) they were aware of the hospital’s foundation, and (2) they have supported the foundation. The majority of respondents were aware of the foundation. A relatively small number of respondents indicated they had supported the foundation, with cash and stock gifts being the most common form of support. Figures 25 and 26 show these results.

Figure 25: Aware of Hospital Foundation?

Figure 26: Supported Hospital Foundation?

131

68

Yes No

1

2

11

20

20

33

0 5 10 15 20 25 30 35

Planned gixs through wills, trusts or life insurance policies

Endowment gixs

Other

CHI Carrington Health employee payroll donaqons

Memorial/Honorarium

Cash or stock gix


Findings from Focus Group and Key Informant Interviews

Questions about the health and well-‐being of the community, similar to those posed in the survey, were explored during key informant interviews with community leaders and health professionals. The themes that emerged from these sources were wide-‐ranging, with some directly associated with health care and others more rooted in broader community matters. Some issues were similar to those that emerged from the survey, while others were not reflected in survey responses. Eight issues were raised:

• Adequate childcare services • Availability of substance abuse/treatment services • Ability to recruit and retain primary care providers • Prevalence of obesity, overweight • Cost of health insurance • Adult alcohol use and abuse • Youth alcohol use and abuse • Political unrest

To provide context for these expressed needs, below are some of the comments that interviewees made about these issues:


• Younger families are moving back and need childcare services • This will help to free up parents who want to work • Lack of services makes economic development a struggle • Options are limited; many daycares not licensed • Problem is getting worse


• People don’t know where to go for help • We need these services locally • These problems are becoming more prevalent • Counselors are overworked



• After loss of physician, I would have liked to have seen a bigger recruiting initiative • We need a more focused attention to recruiting • We have no relationship with locums who are there on weekends • Getting harder to see same provider over time

Prevalence of obesity, overweight

• It starts in grade school • People don’t get out enough • More desk jobs; kids in front of cell phones and videogames


• High deductibles lead to people foregoing visit to provider • There is confusion over insurance marketplaces • For some people a co-‐pay is a burden • This is a huge concern all over


• The bars in this town do well • We need for law enforcement to enforce all drug and alcohol laws, not selective

enforcement


• Parents enable kids’ drinking by hosting parties • This has always been an issue; adults look the other way • Because of rural nature of area, there aren’t as many activities for kids

Political unrest

• Some citizens are against everything, and they make the most noise • Certain agitators get their way by making the most noise • Creates tension in community • Bullying is taking place among the adults • Some county commission meetings have become uncivil and unprofessional


Focus group participants and key informants also were asked to weigh in on community engagement and collaboration of various organizations and stakeholders in the community. Specifically, participants were asked, “On a scale of 1 to 5, with 1 being no collaboration/community engagement and 5 being excellent collaboration/community engagement, how would you rate the collaboration/engagement in the community among these various organizations?” They were then presented with a list of 13 organizations or community segments to rank. According to these participants, public health and faith-‐based organizations are the most engaged in the community, while human services and social services are viewed as having the most room for improvement. The averages of these rankings (with 5 being “excellent” engagement or collaboration) were:

• Public Health -‐ 4.3 • Faith-‐based -‐ 3.9 • Emergency services, including ambulance and fire -‐ 3.8 • Other local health providers, such as dentists and chiropractors -‐ 3.8 • Pharmacies -‐ 3.8 • Schools -‐ 3.8 • Law enforcement -‐ 3.7 • Economic development organizations -‐ 3.6 • Hospital (health care system) -‐ 3.6 • Long term care, including nursing homes and assisted living -‐ 3.6 • Business and industry -‐ 3.5 • Human services -‐ 3.0 • Social Services -‐ 3.0


Priority of Health Needs The Community Group met on May 9, 2016. Sixteen community members of the group attended the meeting. A representative from Prairie Health Partners presented the group with a summary of this report’s findings, including background and explanation about the secondary data, highlights from the survey results (including perceived community assets and concerns, and barriers to care), and findings from the focus group and key informant interviews.

Following the presentation of the assessment findings, and after consideration of and discussion about the findings, all members of the group were asked to identify what they perceived as the top four community health needs. All of the potential needs were listed on large poster boards, and each member was given four stickers so they could place a sticker next to each of the four needs they considered the most significant.

The results were totaled, and the concerns most often cited were:

• Obesity/overweight (12 votes) • Adequate childcare services (10 votes) • Youth alcohol use and abuse (8 votes) • Adult cyber bullying (6 votes) • Adult alcohol use and abuse (5 votes) • Lack of mental health providers (5 votes)

In a second round of “voting,” each member of the group was then given an additional red sticker to place next to the concern they believed was the most important priority of the top six highest ranked priorities. The group chose obesity/overweight as the most important concern, garnering nine votes, followed by youth alcohol use and abuse, with seven votes.

A summary of this prioritization may be found in Appendix C. Table 5 shows the currently prioritized needs along with those prioritized by the community in the previous community health needs assessment.

TABLE 5: COMPARISON OF PRIORITIZED NEEDS FROM PREVIOUS ASSESSMENT

CURRENT CHNA PREVIOUS CHNA

• Obesity/overweight • Adequate childcare services • Youth alcohol use and abuse • Adult cyber bullying • Adult alcohol use and abuse • Lack of mental health providers

• Cancer • Chronic disease management • Higher costs of health care for

consumers • Maintaining EMS • Obesity and physical inactivity


Appendix A1 – Paper Survey Instrument







Appendix A2 – Online Survey Instrument









Appendix B – County Health Rankings Model


Appendix C – Prioritization of Community’s Health Needs

Community Health Needs Assessment Carrington, North Dakota

Ranking of Concerns

The top four concerns for each of seven topic areas, based on the community survey results, along with other concerns from other data sources, were listed on flipcharts. The numbers below indicate the total number of votes (dots) by participating Community Group members. The “Priorities” column lists the number of yellow/green/blue dots placed on the concerns indicating which areas were perceived to be priorities. Each participant was given four dots to place on the items they felt were priorities. After the first round of voting, the top six priorities were selected based on the highest number of votes. Each person was then given one dot to place on the item they viewed as the most important priority of the top six highest ranked priorities. The “’Red Dot’ Round” column lists the number of red dots placed on the flipcharts.

Priorities “Red Dot” Round

DELIVERY OF HEALTH SERVICES Ability to recruit and retain primary care providers Cost of health insurance Cost of health care services Cost of prescription drugs

3 1

AVAILABILITY OF HEALTH SERVICES Availability of primary care providers Availability of specialists Availability to get appointments Availability of substance abuse/treatment services

MENTAL HEALTH AND SUBSTANCE ABUSE Youth alcohol use and abuse Adult alcohol use and abuse Youth drug use and abuse Adult drug use and abuse

8 5 1 1

7

SAFETY/ENVIRONMENTAL HEALTH Adult cyber bullying Emergency services (ambulance & 911) available Youth cyber bullying Traffic safety

6 2

SENIOR POPULATION Availability of resources to help elderly stay in their homes Assisted living options Ability to meet needs of older population Long-‐term/nursing home care options

4


COMMUNITY HEALTH Attracting and retaining young families Affordable housing Adequate childcare services Jobs with livable wages

1

10

PHYSICAL HEALTH Cancer Obesity/overweight Diabetes Poor nutrition, poor eating habits

12

9

OTHER CONCERNS Political unrest Rate of diabetics Physical inactivity Alcohol-‐impaired driving deaths Lack of mental health providers Children in single-‐parent households Injury deaths – Eddy County

2 1 2 5


Appendix D – Response to Previous Assessment

Carrington Health Center

Community Health Needs Assessment

Implementation Strategy Report

Introduction

The Carrington Hospital Association charted on September 23, 1915 and built the original hospital in 1916. In 1941, the hospital was leased to the Sisters of the Presentation of the Blessed Virgin Mary of the Diocese of Fargo, ND. Full ownership was transferred to the Presentation Sisters in 1970. Carrington Health Center is comprised of a hospital, built in 1955, currently used for auxiliary and gift shop, physical therapy, and administration; a Rural Health Clinic, and a hospital complex built in 1986 complete the campus. The Presentation Sisters joined the Catholic Health Corporation of Omaha in 1980 and in 1996, the Catholic Health Corporation consolidated with two other Catholic health systems, the Sisters of Charity Health Care System, Inc., Cincinnati, and the Franciscan Health System, Aston, PA to form a new corporation, Catholic Health Initiatives.

The mission of Carrington Health Center and Catholic Health Initiatives is "to nurture the healing ministry of the church by bringing it new life, energy and viability in the 21st Century. Fidelity to the Gospel urges us to emphasize human dignity and social justice as we move toward the creation of healthier communities."

CHI’s Vision is to live up to our name as one CHI Catholic: Living our Mission and Core Values. Health: Improving the health of the people and communities we serve. Initiatives: Pioneering models and systems of care to enhance care delivery

Carrington Health Center’s goal is to be known as one of the best Critical Access Hospitals in North Dakota that gives the highest quality of patient care.

The primary tax-‐exempt purpose of Carrington Health Center is to provide healthcare services to residents in the community and surrounding area regardless of their ability to pay.

Carrington Health Center provides a wide array of health services for our area including Critical Access Hospital, Emergency Care, Trauma Level 5, Ambulance services, Acute Care, Swing Bed, General Surgery, Patient Education, Pharmacy, Radiology, Laboratory Services, Physical Therapy, Occupation Therapy, Speech Therapy, Monitored Coronary Care, Respiratory Therapy, Cancer treatments, Same-‐Day Surgery, Ultrasound, DEXA Scans, CT Scanning, Electrocardiography, Medical Nutrition Therapy, Diabetes Education, Mammography, a full Clinic


and outreach clinic in New Rockford, Eddy County. Medical Providers include: with three physicians, a general surgeon, three Physician Assistants and many outreach specialists that provide needed local services for which our patients would otherwise have the inconvenience of traveling long distance to receive. In addition to the 25-‐bed critical access hospital, Carrington Health Center operates two rural health clinics. One is attached to the hospital and the other is located in New Rockford, ND a community 16 miles north of Carrington.

The Community Health Needs Assessment was conducted through a joint effort, CHC and the Center for Rural Health at the University Of North Dakota School Of Medicine and Health Sciences analyzed community health-‐related data and solicited input from community members and area health care professionals. The Center for Rural Health’s involvement was funded through its Medicare Rural Hospital Flexibility (Flex) Program. The Flex Program is federally funded by the Office of Rural Health Policy and as such associated costs of the assessment were covered by a federal grant.

To gather feedback from the community, residents of the health care service area and local health care professionals were given the chance to participate in a survey. Additional information was collected through a Community Group comprised of community leaders as well as through key informant interviews. The survey period ran from April 16 to June 15, 2012.

Identified Geographic Area and Populations

Carrington Health Center is located in a frontier area and is licensed as a critical access hospital; located in Carrington in east central North Dakota, just two hours from four major cities in North Dakota: Fargo, Minot, Grand Forks, and Bismarck. Its economy is based on agri-‐business, service industries, and retail trade. Counties served by CHC include Foster County, Eddy County, portion of Stutsman, Wells and Griggs Counties – which these last three have a medical center in their county. The 3 major counties for CHC services are Foster, Eddy and Wells. According to the U.S. Census Bureau estimated census for 2011: these 3 counties have a total area of 2,536 square miles and approximately 9,958 people, a slight increase from 2010 census of 9,935. The racial makeup of the counties was 97.6% white. The number of households decreased from 4806 to 4601households. Census statistics show 20% of children are under the age of 18 and 24.8% of the population is 65 years of age and older. The median age was 43 years. The median household income in the 3 counties decreased from $42,532 to $39,869 and the population below the poverty line decreased from 11.26% to 10.9%.

How the Implementation Strategy was Developed

Attachment: Community Health Needs Assessment

Who was involved in the implementation strategy development; what roles did they play.

Implementation Strategy Development was completed by

Mariann Doeling, President, Carrington Health Center

Jan Bakke, Mission / Spiritual Care Coordinator, Healthy Communities Initiative Committee

Nicole Threadgold, Executive Foundation Coordinator


Jennifer Whitman, Wellness and Disease Management Coordinator

Marilyn Anderson, Social Service and Community Benefit Coordinator

Major Community Health Needs Identified and How Priorities were Established

The following community needs were identified and prioritized into tiers by those who completed the CHNA. The strategies and community efforts to address these needs are listed for Tier #1 and Tier #2. Description of What Hospital will do to Address Community Health Needs and Action Plan: TIER #1

a) Elevated rates of adult diabetics -‐ Early in 2012, CHC’s Diabetes Education Program attained accreditation through a partnership with the North Region Health Alliance (NRHA). The goal of the NRHA is to provide diabetics in NRHA communities’ access to high quality diabetes care. In order to maintain accreditation, CHC must complete the following activities each year. CHC will hold three free diabetes awareness events per year that will serve to raise the level of diabetes community awareness. A Diabetes Education Brochure will be available to assist with program promotion. Annual education visit reminder letters will be sent out based on when the patient either completed the education or had his/her last documented visit. CHC will hold at least one staff diabetes education training program per year for hospital or clinic personnel, including medical staff, nursing, pharmacy and others as appropriate. The goal for participant access to diabetes education cumulatively = 33%, calculated by dividing the number of patients with diabetes referred for diabetes education by the total number of patients with diabetes. Education staff will review the billing process at their site twice a year, to monitor that appropriate codes are being used, and that charges are appropriate.

• Update: March 2014 – CHC remained in compliance during the accreditation year (October 1, 2012-‐September 30, 2013) with meeting the accreditation standards and continues to meet these requirements presently. Participant access to diabetes education was at 15.2% and is expected to continue to rise. This goal was set by the alliance and has been discontinued for the next reporting year. The reason for this change was that this goal is hard to attain for new programs, and hard to sustain for older programs. The other change made for this year is to send each patient that receives diabetes education services a satisfaction survey which has been implemented. However, the current survey will be updated to reflect best practices from the Service Excellence Initiative.

• Update: December 2015 -‐ CHC continues to remain in compliance with meeting the accreditation standards for the Diabetes Education program. In the fall of 2014 a new service line, telemedicine for diabetes care, was implemented to further enhance the treatment of diabetic patients. This service line reduces costs for our patients by enabling them to receive specialist care locally through the use of technology.


b) Elevated rate of adult obesity – CHC currently offers a Weight Management Support Group that meets the first Wednesday of each month. This group is intended for those who are interested in weight-‐loss regardless of the amount of weight they would like to lose or whether they have had bariatric surgery. This group offers practical tips and knowledge to help in the weight loss journey. Group meetings consist of guest speakers, discussions, and question and answer sessions. Group topics include dealing with not only the nutritional and physical health, but also emotional, mental, psychological and spiritual well-‐being.

• CHC currently has grant funding to address obesity through the following objectives focused on physical activity and nutrition. The first objective is to enhance the health of our community through nutrition classes taught by CHC’s Dietitian to the Foster County employee wellness group, Carrington Health Center employees, and Carrington Public School employees, students, athletes, and their parents. Nutrition classes will be specifically designed to meet the needs of each group. Expected outcomes are changes in self-‐evaluation pre-‐ and one month post-‐class and increased use of nutrition services at Carrington Health Center. This objective will first be rolled out with the grant partners listed above to test the feasibility of offering this service to other community groups in the future.

• The second objective is to increase physical activity opportunities in the community through a “Fitness on Request” kiosk at Carrington Fitness Center. Fitness on Request impacts a number of people with its variety of classes that could not be offered otherwise. Users can access 40 different classes on demand from a touch screen kiosk, projector, 120” screen, and speakers. The instructor talks you through the exercise and an assistant demonstrates. Groups participating in the nutritional classes will use Fitness on Request at no charge during their group’s timeslot. Measurable outcomes are increased activity among the groups and memberships to Carrington Fitness Center.

• The third objective is to increase physical activity opportunities for Carrington Health Center’s employees and its Worksite Wellness program. An industrial grade treadmill has been purchased for the employee fitness room that opened in January 2013. This program has offered a variety of activities over the past two years. Most recently an interactive website was launched for wellness, nutrition and fitness challenges/tracking. Other equipment has been purchased or donated for the fitness room valued at $6,500. Outcomes are increased use of the employee fitness room by sign-‐in sheet monitoring; and, activity logs through the worksite wellness website. These efforts are being coordinated through the CHC Wellness & Disease Management Department.

• Update: March 2014 – The three items listed above have been completed. CHC is currently facilitating a Wellness Treatment Program. The program includes a total of 13 participants starting in February 2014 and completing in August 2014. Each participant had initial biometrics collected. Biometrics include the person’s height, weight, body mass index, and hip and waist circumference. They will also have blood work done if they have not recently had a draw to determine their cholesterol and fasting glucose. A Body Stat reading, which is more in-‐depth than just stepping on a


scale, will give insight into a person’s hydration level, caloric needs and muscle mass. Once these baselines are established, the group will begin monthly shared medical appointments with Foster County Medical Center’s Physician’s Assistants. Groups of around 9 people who share common diagnoses will benefit from a group appointment. Each person’s vitals will be taken at the beginning of the appointment. The focus will then shift towards a specific topic for the group. Interaction and group dynamics amongst participants is a benefit to this type of appointment. Weekly Health Coaching also occurs to encourage participants and address any challenges to their success. Another important part of managing a person’s wellness is nutrition. Initial visits with Carrington Health Center’s dietitian will help participants to create a meal plan that compliments their health goals. Rounding out a person’s wellness is physical activity. The need for physical activity in a person’s life can vary greatly upon their health, the weather and finances. A physical therapist will visit with the group to design a low cost at-‐home exercise plan. Attendance at the monthly Weight Management Support Group is encouraged. Throughout the program, Body Stat readings will be updated so participants can see the changes occurring inside their bodies. In August, biometrics and another blood draw will complete the program to show changes for each participant. Although wellness and managing chronic conditions such as diabetes are being heavily focused on in healthcare, insurance coverage is still evolving to help pay for these services. The Flex program is helping us reduce that challenge by covering half of a person’s out-‐of-‐pocket costs to participate in the program. This makes is very affordable for a person be in the program.

• Update: December 2015 -‐ During 2015, Carrington Health Center was the recipient of the Blue Cross Blue Shield of North Dakota Rural Health Grant Program: Official Sponsor of Recess Partnership. Carrington’s implementation project had two goals: to enhance the health of our community through nutrition and increase opportunities for physical activity in the community. These goals were achieved through Carrington Health Center and its medical staff partnering with seven additional healthcare providers in Carrington, the Foster County Fairgrounds, SuperValu Foods and KDAK 1600AM. Activities included nutritional food preparation classes and grocery store tours, Foster County Fair Kids Day activities, and a 12 week Health Talk & Walk program hosted by community healthcare providers. The Health Talk & Walk program combined a weekly radio segment on Tuesday mornings followed by a Tuesday evening walk in the park, hosted by various community medical professionals.

c) Cancer – This winter, CHC added digital mammography to the radiology department to

increase early detection of breast cancer. This was made possible through a three year grant, currently in year one. The grant supported the purchase of full field digital mammography equipment and installation, staff training, and community outreach at CHC. The National Cancer Institute's Digital Mammographic Imaging Screening Trial (DMIST) showed significant image quality advantages of digital mammography for several patient


categories, specifically those with dense breast tissue, women under age 50, and premenopausal or peri-‐menopausal women. At CHC, an estimated 30-‐35% of those screened has dense breast tissue and will particularly benefit from digital imaging. Digital mammography can be key to pinpointing breast cancers when a tumor is small and most treatable.

• CHC is also working to establish a contractual relationship for oncology services due

to the discontinuation of contracted services for oncology last fall. • Update: June 2016 – Digital mammography is in the final year of the grant. It was

originally a 3 year grant and we had a no cost extension to a fourth year to finish using the marketing budget. New relationships are being forged due to the purchase of St. Alexius Health by CHI. This spring a cardiologist and an orthopedic specialist begin seeing patients in Carrington and were the first two specialties gained through the CHI St. Alexius Health network. There are several more specialties that CHC is pursuing through CHI St. Alexius Health in Bismarck. Also formed this spring was the Clinically Integrated Network with CHI St. Alexius Health. CHI St. Alexius Health is now the largest health delivery system in the region with over 50 points of care and more than 400 physicians and advance practice clinicians with the network extending across ND and dipping into SD.

TIER #2

a) Higher costs of health care/insurance/elevated rate of uninsured residents – CHC is working to increase community awareness of insurance wellness benefits and how to apply those benefits to existing community resources. Presentations to the grant partners at Foster County, Carrington Health Center, and Carrington Public School will share information about preventative services, evidence based practices for chronic diseases, and other wellness benefits. Expected outcomes are increased use of wellness and preventative benefits at CHC and Foster County Public Health.

• A Patient Financial Advocate is on staff at CHC who works with those needing information on the cost of their medical bills. The advocate assists in researching insurance coverage and establishing payment plans. The advocate also provides information on Medicaid, Medicare and charity care. This position was created by CHC in response to the desire to decrease bad debt and encourage patients to apply for financial assistance.

• Update: March 2014 – Please see March 2014 update for “elevated rate of adult obesity” as these updates are closely related.

• Update: December 2015 – The Patient Financial Advocate role continues to provide support and advocacy for patients around their financial obligations and access to financial programs.

b) Inadequate/decreasing number of volunteers – Decreasing Ambulance volunteers has been a concern of CHC. Ongoing efforts to increase awareness in the community of this shortage are being made. These efforts include: working with the local newspapers to tell


our story, and the effects of our volunteer shortage; offering open house informational meetings to learn more about the requirements of becoming a volunteer EMT; the coordination and education of EMT classes; grant writing to fund a salaried EMT position, alleviating some reliance on EMT volunteers; and, grant writing to fund an incentive plan where current ambulance volunteers who increase their monthly call hours receive a monetary bonus. A one-‐year grant was awarded to CHC to fund the EMT position and call bonus incentive plan. This grant will allow us to test the impact of the additional EMT position and incentive plan. If successful, this would allow us to consider budgeting for these items in following fiscal years.

• Update: December 2015 -‐ The incentive did not work. We continue to receive the annual State EMS grant and local mil levies, but still operate at a loss each year. Our EMS service is still in a state of need. Our staffing model has transitioned to that of being primarily staffed by hourly positions and supplemented by PRN drivers. The entire state of North Dakota is experiencing the same decline in EMS services. We are seeing an even bigger impact due to being a hospital based EMS service with our Medicare regulations versus those not owned by a hospital.

c) Elevated rate of excessive drinking -‐ Carrington Health Center’s Healthy Communities

Coalition was awarded the “Targeted Community” award through the ND Dept. of Health and Human Services Drug and Alcohol Division. Alcohol abuse has long been an on-‐going battle within our community; the Healthy Communities Coalition has been trying to address this issue for many years. Being a Targeted Community allows us to focus on drug and alcohol prevention. We have completed an assessment and strategic plan that includes effective evidence-‐based practices and strategies.

• A grant was received to offer Alcohol Server Training to both Eddy and Foster Counties to address education on this issue. All alcohol servers within Eddy and Foster Counties will receive this training to help combat alcohol availability to minors. We are currently waiting on a second compliance check to measure the impact.

• Update: December 2015 -‐ Completed Targeted Community Program activities included:

i. The Carrington Health Center’s Healthy Communities Coalition created strategic plans for the priority issues of underage drinking and adult binge drinking, which were determined from the 2013 CHNA.

ii. The Foster County Independent ran articles submitted by the Department of Human Services on behalf of the Carrington Health Center’s Healthy Communities Coalition on a bi-‐monthly basis that was titled “Above the Influence with Healthy Communities.” The articles were focused on the health and well-‐being of youth in the community.

iii. Dakota Central Telecommunications (Channel 17) has run slides free of charge for the Carrington Health Center’s Healthy Communities Coalition. The first slides were submitted to DCT in March 2012. Additional slides have run to coincide with the campaign and events.


iv. KDAK radio has recorded and played PSA’s about ongoing campaigns when requested by the coalition. PSA’s were created for: Prescription Drug campaign, Red Ribbon Week, and Positive Messaging Campaign.

v. Tag It activities were completed with Sources of Strength youth. Elementary Students colored Above the Influence symbols and they were placed in a vacant store front on Main Street. A video of Carrington’s Above the Influence ‘Tag It’ activities was created and can be viewed on YouTube as well as on the Carrington prevention website.

vi. The Carrington Health Center’s Healthy Communities Coalition selected 2 images and 2 positive messaging statements to use in their positive messaging campaign. They were distributed at various locations around town as well as in grocery bags.

vii. Two billboards were placed around the Carrington area during July and August 2012 to create awareness about prescription drug abuse. Fifteen hundred flyers were created to help reduce access to Prescription medication from those who do not legitimately need them and to remind residents to utilize the local Take Back Programs at the Foster County Sheriff’s Department and the Carrington Police Department.

viii. Compliance Checks in local establishments were conducted October 2012. Server Training classes were offered October 2012 through April 2013.

ix. Alternative Events were offered to youth and community members such as: New Year’s Eve Alternative Event-‐2010, Senior Bash-‐2012, National Night Out-‐2011/2012, and Don’t get benched by alcohol-‐Class B Basketball.

x. Red Ribbon week activities facilitated by CHC’s Healthy Communities Coalition in 2011 and 2012 include: PSA’s on KDAK, created video of Red Ribbon Week activities that can be viewed here, Sources of Strength youth read ‘How Full is your Bucket’ book to elementary students, school focused on conflict resolution, 310 Red Ribbons on business cards (with description of purpose) were distributed to local businesses and available for community members to take and display/wear, Red Ribbon Week Proclamation, DCT slide/Ad sent to newspaper.

• Update: June 2016 -‐ Foster County Public Health (FCPH) was the recipient of the Strategic Prevention Framework State Incentive Grant (SPF SIG), a four year SAMHSA grant, starting in 2013. CHC’s Healthy Communities Coalition collaborated with FCPH to continue to work on prevention efforts to address adult and youth alcohol use. Some of the activities completed through this grant by the FCPH and CHC’s Healthy Communities Coalition include:

i. Responsible Event Assessments -‐ Conducted to look at events where alcohol is served to determine suggestions that can be made organizers to deter adult binge drinking and youth drinking at events. (3) REA’s conducted.

ii. Compliance Checks and Shoulder Taps Efforts – Use of under-‐age youth decoy(s) entering a liquor establishment to purchase alcohol or approaching an adult outside a liquor establishment, and asking the adult to purchase alcohol for the decoy. (2) Events performed (5) liquor establishments checked.


iii. Responsible Beverage Service (RBS) Trainings/ID Scanners -‐ Merchants were trained on ID Scanners, responsible service of alcohol, and laws/penalties to selling to minors. (7)Trainings held, (26) Servers Trained, and (20) ID Scanners distributed.

iv. Policy Change – Meetings with City Council of Carrington to attempt passage of an ordinance for mandatory RBS Training and Compliance Checks. (1) Policy change presented (1) Policy failed.

v. Regional Network -‐ Developed a regional list (10 law enforcement agencies) to contact for Compliance Checks and Enhanced Efforts events. Network will aid in increased law enforcement for events in shortage areas.

Priority Community Health Needs Not Being Addressed by the Hospital and Reasons Why a) At this time we are addressing the top three Tier #1 community health needs and the top

four Tier #2 community health needs. The higher costs of health care/insurance and the elevated rate of uninsured residents are being addressed as one. The other tier 2 needs will not be addressed at this time in order to focus on the top needs identified in Tier #1. The Identified elevated level of sexually transmitted infections is addressed by the Foster County Public Health office which offers education, examination and treatment of sexually transmitted diseases. Emergency services are available 24/7 -‐ CHC is a critical access hospital designated as a trauma level 5 emergency room.

b) Tier 3 received less than 5 votes each. These conditions are interrelated and have been addressed through the previously mentioned Wellness & Disease Management efforts in obesity. However we also have a Tobacco Prevention Coordinator in our community through Foster County Public Health system. Carrington Health Center’s Healthy Communities Coalition has worked with the Tobacco Coordinator to educate our community on the need for a public smoking ban in North Dakota which was successful in passing and in effect as of December 2012. CHC’s Cardiac Rehab is available for public self-‐pay supervised exercise.

Approval

This strategic plan for Carrington Health Center’s Community Health Needs Assessment and Implementation Strategy Plans were approved by the Board of Directors on March 19, 2013.

Annual Review of the strategic plan for Carrington Health Center’s Community Health Needs Assessment and Implementation Strategy Plans will be included in the Fiscal Year 2013 IRS 990 Schedule H narrative. The IRS 990 Schedule H narrative will be approved by the Board of Directors by December 31, 2013.

Documents

Co mmu n i t y Heal t h Need s Assessmen t Car r ington Ar ea · 2016 Co mmu n i t y Heal t h Need s Assessmen t Car r ington Ar ea Nort h Dakot a K e n Hall, J D Shana L . W. Hall,